Andrea* went to the ER in an unresponsive state. She thought she was having a seizure. While she could hear, she could not see, speak, or move voluntarily. When she arrived at the ER, before she was assigned a room, she heard two men discussing whether she was faking her symptoms or if she was a drug addict. One of them advocated that the other move her limbs until she responded. When they moved her shoulder, she started crying because of pain due to a previously existing shoulder injury. However, she still could not talk or pull her arm away. The men interpreted her tears as evidence that she was indeed faking and they continued to move her arm.
Tonic Immobility, once called “rape paralysis,” is a part of the Cascade of Defenses shared by humans as well as all mammals. Most people are familiar with the first 3 defenses: fight, flight, and freeze. All three of these defenses put a mammal in a state of hyperarousal in order to prepare them for escape.
Less commonly known defenses are Tonic and Collapsed Immobility. Instead of preparing a mammal for escape, these defenses prepare us for death through the activation of the parasympathetic nervous system. Animals experience Immobility when they cannot escape a predator. Humans experience these defenses in response to traumatic events that may or may not include the threat of death. We can also experience Tonic and Collapsed Immobility in response to reminders of past traumatic events.
The difference between Tonic and Collapsed Immobility is a person’s level of consciousness. People in a state of Tonic Immobility, such as Andrea and Chris, remain conscious. Collapsed Immobility is a more extreme state where a person collapses into unconsciousness or semi-consciousness due to bradycardia and a lack of brain oxygen. Children are especially vulnerable to states of Tonic and Collapsed Immobility, as are adults who were traumatized as children.
States of Tonic Immobility can last from minutes to hours to days. During a state of Tonic Immobility, a person is conscious and may be able to walk, sit upright, and/or stand. Their eyes are often closed. If their eyes are open, their stare appears vacant. They cannot speak or move their limbs outside of what keeps them from bodily collapse. An article from the Harvard Review of Psychiatry describes a person’s internal experience in this state in the following way:
“Victims describe subjective experiences of fear, immobility, coldness, numbness and analgesia, uncontrollable shaking, eye closure, and dissociation (derealization and depersonalization), as well as a sense of entrapment, inescapability, futility, or hopelessness.” **
So, while people in this state appear calm, they are actually terrified. Most people retain a clear memory of what happened to them after they are no longer in a state of Tonic Immobility.
I encourage medical professionals to learn about Tonic Immobility, and share the information with colleagues. If you have an unresponsive patient, do not assume they are faking or have ingested a substance. Check their chart to see if they have PTSD or a Dissociative Disorder. If they cannot initially verbally consent to even simple medical instructions, talk to them in a calming and soothing manner, give them time to respond; and, if medically feasible, leave the room to give them time to calm down enough to talk. If they still cannot consent verbally, see if they are able to blink their eyes or lift even a finger to communicate yes or no. If so, seek consent for every step of the medical procedures needed using these signals.
When someone is in a state of Tonic Immobility, do not try to move them physically, other than doing tests necessary for medical screening. If they are unable to change into a medical gown, do not remove their clothing unless absolutely necessary. Many people who suffer with Tonic Immobility are survivors of sexual assault; therefore involuntary clothing removal can increase their perception of threat. When a client perceives increased threat while already in a state of Tonic Immobility, Tonic Immobility may be prolonged or intensified and Collapsed Immobility is possible. As you perform medical procedures, remember that people in this state cannot communicate they are in pain but will remember everything you say or do. If Tonic or Collapsed Immobility is suspected, encourage them to follow up with a Psychologist or other mental health clinician who specializes in PTSD and Dissociative disorders.
Many of us in the field of mental health do not learn about the full range of trauma responses, even in graduate school. It’s important that we seek continuing education on how trauma impacts the body so we can properly diagnose clients who come to us for care. Clients usually feel relieved on multiple levels when Tonic and Collapsed Immobility are diagnosed. Sometimes, these symptoms have left them vulnerable to more trauma. Once clients are aware of the reason for their paralysis, they have more power to self-advocate and may come to feel less shame about their lack of protest when experiencing Tonic Immobility.
I would like to encourage readers who have experienced Tonic and Collapsed Immobility. You are not alone. You are not faking. You are not weak. You are not crazy. You do not have a seizure disorder. You are not having a stroke. You are not in a catatonic state, requiring anti-psychotic medication. You experience Tonic Immobility because you have been traumatized. If you haven’t received treatment for trauma, consider finding a trauma-informed psychotherapist. If you have experienced Tonic Immobility in a medical setting, your mental health professional can give you documentation to bring with you to medical appointments and the ER that includes your diagnosis and recommendations. If you have a support person that helps you feel safe, thereby reducing your risk of Tonic Immobility, bring them with you when you need medical assistance. In anticipation of possible restrictions due to COVID19, consider asking your mental health professional to document the necessity of bringing your support person when receiving medical care.
If you want to learn more, Stephen Porges’s Polyvagal Theory provides a clear explanatory framework for the neurophysiology of the Cascade of Defenses: fighting, fleeing, freezing, Tonic Immobility, and Collapsed Immobility. In addition, the International Study of Trauma and Dissociation has many academic and practical resources for professionals and trauma survivors who experience a wide range of lesser known symptoms in response to trauma, including Tonic Immobility.
As medical and mental health professionals, we desire for our systems to be a source of healing, not re-traumatization. Trauma survivors are among the most vulnerable people who come to us for care. With a deeper understanding of their experience, we can better serve our affected patients and clients.
*Names and some details were changed for the purpose of confidentiality.
*Kozlowska K, Walker P, McLean L, Carrive P. (2015) Fear and the Defense Cascade: Clinical Implications and Management. Harvard Review of Psychiatry 23(4): 263–287.